(Select all that apply - Online ATI/HESI question): A nurse is performing sterile suctioning on a patient. Which of the following are appropriate infection control measures for this procedure? Select all that apply.

Environmental cleaning before suctioning.

Using a reusable suctioning catheter.

Proper disposal of used catheters into a regular trash bin.

Hand hygiene before and after the procedure.

Wearing gloves and a mask during suctioning.

Answer and Explanation

Correct Answer : A,D,E

Choice A rationale:

Environmental cleaning before suctioning is crucial to maintain a clean and safe environment for the patient. This reduces the risk of introducing additional contaminants during the procedure.

Choice B rationale:

Using a reusable suctioning catheter is not appropriate for infection control measures. Reusable catheters can harbor microorganisms, even after proper cleaning and sterilization, increasing the risk of cross-contamination.

Choice C rationale:

Proper disposal of used catheters into a regular trash bin is not a suitable infection control measure. Used catheters should be disposed of in designated biohazard containers to prevent exposure to potential pathogens.

Choice D rationale:

Hand hygiene before and after the procedure is essential to reduce the transmission of microorganisms to and from the patient.

Choice E rationale:

Wearing gloves and a mask during suctioning helps protect the nurse from exposure to the patient's bodily fluids and potential infectious agents.

Repeat steps 7 to 9 until no more secretions are obtained or until three passes are completed. Do not suction more than three times in a row to prevent complications. Allow at least one minute of rest between each suction pass to prevent fatigue and distress .

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Correct Answer is B

Explanation

Choice A rationale:

The nurse should indeed provide reassurance and answer any questions before performing any procedure, as this helps to alleviate the patient's anxiety and ensure they are well-informed about the procedure.

Choice B rationale:

Gathering the necessary equipment and supplies is essential before starting sterile suctioning. This ensures that the nurse has everything needed for the procedure, promoting efficiency and safety.

Choice C rationale:

Connecting the suction tubing to the suction device is an important step in the suctioning process, but it should be done after gathering all the necessary equipment and supplies.

Choice D rationale:

Preoxygenating the patient with 100% oxygen is not a step required before suctioning. Preoxygenation may be necessary before some procedures, but it is not specifically indicated for sterile suctioning.

A. "I have a history of epiglottitis.". B. "I sometimes get laryngeal edema.". C. "I have difficulty clearing my secretions.". D. "I use an artificial airway at night.".

Correct Answer is A

Explanation

Choice A rationale:

Epiglottitis is an inflammation of the epiglottis, which is a crucial structure in protecting the airway during swallowing. Suctioning in patients with a history of epiglottitis can be dangerous because it can cause further irritation and swelling of the epiglottis, potentially leading to airway obstruction and respiratory distress. Therefore, sterile suctioning is contraindicated in patients with a history of epiglottitis.

Choice B rationale:

Laryngeal edema refers to swelling of the larynx, which can also compromise the airway. While it is essential to monitor and manage laryngeal edema carefully, it is not an absolute contraindication for sterile suctioning. In some cases, suctioning may be necessary to maintain a patent airway, but it should be performed with caution and by experienced personnel.

Choice C rationale:

Difficulty clearing secretions is a common indication for sterile suctioning. Patients who have difficulty clearing their secretions may need suctioning to prevent the accumulation of mucus and maintain a clear airway. Therefore, this statement does not indicate a contraindication for the procedure.

Choice D rationale:

Using an artificial airway at night, such as a tracheostomy tube, indicates that the patient may require suctioning to maintain airway patency. While having an artificial airway increases the risk of infection and other complications, it is not a contraindication for sterile suctioning if clinically indicated.

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(Select all that apply - Online ATI/HESI question): A nurse is performing sterile suctioning on a patient. Which of the following are appropriate infection control measures for this procedure? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform sterile suctioning on a patient. What should the nurse do before suctioning?

Correct Answer is B

Explanation

A nurse is educating a group of patients about sterile suctioning. Which patient statement indicates a contraindication for this procedure?

Correct Answer is A

Explanation

A client expresses concern about the suctioning procedure. What is the best response by the nurse?

During sterile suctioning, the nurse observes the patient experiencing bronchospasm and increased intracranial pressure. What should be the nurse's immediate action?

A client with a history of bleeding disorder requires suctioning. Which statement indicates that the nurse should not proceed with the procedure?

A client has a nasopharyngeal tube (NPT) for oxygenation. During the suctioning procedure, the patient says, "I'm experiencing discomfort in my nose.” How should the nurse respond?

A nurse is performing sterile suctioning and observes the patient's oxygen saturation dropping below the normal range. Which statement by the nurse is appropriate?

A nurse has completed sterile suctioning for a patient with an endotracheal tube (ETT). What should the nurse do next?

A nurse is performing tracheostomy care for a patient with a tracheostomy tube (TT). Which action should the nurse include in the procedure?

(Select all that apply): A nurse is preparing to perform nasopharyngeal suctioning for a patient with a nasopharyngeal tube (NPT). What actions should the nurse take during the procedure? Select all that apply.